THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

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1 THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please list your health objectives/goals regarding this consultation and/or treatment: Personal History: Concerns: Please list your health concerns. How long have they troubled you? Please describe any other conditions that are currently bothering you, such as: Aches, pains, degenerative illnesses, stress, fatigue, constipation, high blood pressure, high cholesterol, energy levels, mental clarity, concentration, vision, fever, hot flashes, chills, insomnia, nervousness, or other conditions that you can think of: Are you under a physician s care now? Why? Are you taking any prescription drugs or medications? What surgeries have you had?

2 When? Last physical examination (date)? Height Weight Cholesterol Blood Pressure Do you or your parents, brothers or sisters have history of the following: (Please put an X in the appropriate column.) Allergies to Food or Drugs Cancer Chemotherapy/Radiation Treatment Heart Disease/Heart Murmur Arthritis Heart Attack/Heart Surgery Chest Pain Shortness of Breath Swelling of Feet or Ankles Stroke High or Low Blood Pressure Prolonged bleeding when cut Asthma, Pneumonia, TB Anemia Mononucleosis, Hepatitis, Jaundice, Gallstone Diabetes Fainting, Dizziness Ulcers, Intestinal Bleeding Hemorrhoids Kidney or Bladder disease HIV exposure Epilepsy, Convulsions, Seizures Thyroid Disease or Medication Glaucoma, Eye surgery Contact Lenses Implants, Prosthesis Pain or Ringing in the Ears Ear infections or any kind of problems Popping, clicking or locking of the Jaw Psychiatric Treatment Venereal Diseases Complicated Dental Treatment Myself Family Member Myself Family Member

3 Please list any other disease or problems not listed above: If female, are you pregnant? Taking birth control pills? Last menstrual cycle? I acknowledge that this consultation is for educational purposes, that this is not a substitute for medical care and diagnosis and I take full responsibility for my health. Client Signature Date

4 Tell us about the staples of your diet. What do you usually eat for: Breakfast Lunch Dinner Snacks Beverages (water, caffeine, alcohol)

5 AYURVEDIC CENTER OF VERMONT, LLC Informed Consent Ayurveda is the traditional healing system of India, and is based on the idea that each person s path toward optimal health is unique. The advice given to you by an Ayurvedic practitioner is based on understanding your unique constitution and your imbalances. Your program may include lifestyle adjustments, dietary changes, herbs, color therapy, sound therapy, aromatherapy, massage therapy, and other natural therapeutics. The goal of all programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body s ability to heal itself. The Ayurvedic Center of Vermont is not a Medical Facility. Employees of The Ayurvedic Center of Vermont, may not be trained in Western diagnosis or treatment and may not make suggestions about altering your medical care. Allison Bransfield Morse, the principle of The Ayurvedic Center of Vermont, is an Ayurvedic Lifestyle Counselor. She is not a Medical Doctor. The National Institute of Health, Office of Complementary and Alternative Medicine currently considers Ayurveda a form of complementary and alternative medicine in the United States. In the State of Vermont, Ayurveda is a non licensed profession. If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional, we recommend that you receive a proper evaluation and may provide you with a referral form. If you are referred to a Medical Doctor, you will be required to sign an acknowledgement that one was recommended to you. No one in association with The Ayurvedic Center of Vermont, may recommend altering your prescriptions without the approval of your medical doctor. Your practitioner may suggest that you speak to your doctor about reducing medication when he/she feels that it is appropriate. While your practitioner may take your blood pressure and vital signs, and perform some examination techniques similar to a routine medical examination, your practitioner is evaluating their findings from an Ayurvedic perspective only and not from a Western medical perspective. This examination does not take place of a medical exam. If, as a result of our evaluation, any findings suggestive a possible Western medical imbalance, your practitioner will refer you to a Medical Doctor for further evaluation. The Ayurvedic Center of Vermont does not diagnosis pathological conditions from a Western perspective and we do not offer treatment for pathological conditions. We are strengthening your body to function properly, not treating a specific pathological condition. For Panchakarma Clients: Cancellation Policy once you have arrived for your PK, your credit card will be charged the full amount for the week and is nonrefundable. I have read and understand the above information and give my permission to begin a program of Ayurvedic health care with The Ayurvedic Center of Vermont and take full responsibility for my healing. Client s Signature: Date:

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